Refer A Patient

Please use the contact forms below to send us information on referrals. Or you may download a form if you prefer.

    Referral to Ian Cross, Specialist Endodontist & Prosthodontist

    Root Canal WorkRestorative Work

    Your Details

    (You will receive a copy by email of the infomation you submit)
    Name

    Email

    Patient Details

    Name

    Gender
    FemaleMale

    Date of birth

    Address

    Postcode

    Email

    Telephone Numbers
    Home
    Work
    Mobile

    Referral Reason

    History of present complaint

    Relevant Medical History (including medications/allergies)

    Any treatment carried out already (It would be helpful if a radiograph is forwarded with this form)


    Other relevant information

    Referring GDP Details

    GDP Address

    GDP Telephone

    GDP Email

      Referral to Mamdouh Al Chihabi, Speciality Dentist in Paediatric Dentistry

      Your Details

      (You will receive a copy by email of the infomation you submit)
      Name

      Email

      Patient Details

      Name

      Gender
      FemaleMale

      Date of birth

      Address

      Postcode

      Email

      Telephone Numbers
      Home
      Work
      Mobile

      Referral Reason

      History of present complaint

      Relevant Medical History (including medications/allergies)

      Any treatment carried out already (It would be helpful if a radiograph is forwarded with this form)


      Other relevant information

      Reffering GDP Details

      GDP Address

      GDP Telephone

      GDP Email

      Download Referral Forms

      Ian Cross - Referral Form (PDF)

      Specialist Endodontist & Prosthodontis

      Mamdouh Al Chihabi - Referral Form (PDF)

      Speciality Paediatric Dentist

      The Bramhope Dental Clinic
      2 Breary Lane East
      Bramhope
      Leeds LS16 9BJ

      0113 2300359

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      At The Bramhope Dental Clinic, the need for strict confidentiality of personal information about our patients is taken very seriously.   We have a ‘Confidentiality policy’ which is a condition of employment for all staff members which ensures that any information revealed by our patient to the dentist, nurse or reception team will not be divulged without our patient’s written consent.

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